Fillable Keweenaw Bay Indian Community (Keweenaw Bay Indian Community)

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Keweenaw Bay Indian Community (Keweenaw Bay Indian Community)

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Country of origin: US
File type: PDF

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Return form to: Enrollment Department/Coronavirus Support Program
16429 Beartown Rd., Baraga MI 49908
Keweenaw Bay Indian Community
Coronavirus Support Program
Address Verification Form
(Must be signed in the presence of a Notary Public)
Name:_____________________________________________________________________________________________
DOB:_____________________________SS#:_________________________________Enroll #____________________
Mailing Address:____________________________________________________________________________________
City:___________________________State:___________Zip:___________________County:_____________________
Physical Address (if different from
mailing):____________________________________________________________________________________________
City:___________________________State:___________Zip:___________________County:_____________________
Home Phone:___________________________________Cell Phone:________________________________________
Email:________________________________________________________________________________________________
I certify that I am in need of assistance from the Covid Support Program for one of the following
reasons:
____Rent/Housing Assistance ____Purchase personal protective equipment
____Emergency needs ____Currently laid-off/unemployed
____Food Support
Print Name:_________________________________________________________________________________________
Signature:_________________________________________________________ Date:____________________________
Certificate of Notary Public In the State of__________, County of_______________________this document was
Signed before me on this___________date of________________in the year____________
Notary Signature:___________________________________________________________________
Commission Expires:______________________________________
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Keweenaw Bay Indian Community (Keweenaw Bay Indian Community)

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Completed 20 July 2020

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